Wheaton College Norton, Massachusetts
Wheaton College
Wallace Library

Academics

Sample Request Letter

(Return address)

(Date)

Name of copyright holder or Permissions Department
(Publisher)
(Address)

Dear (title, name):

I am a (faculty/student) at Wheaton College. I seek your permission to (indicate those which apply):

  • reprint
  • photocopy
  • quote from
  • incorporate into ...
  • digitize

the following:

  • multimedia courseware
  • online course materials
  • dissertation/thesis
  • print publication
  • Web site material

Describe item(s) with the full citation of the original work including:
Creator:_____________________________________________________
Title:_______________________________________________________
Edition or date:________
Portion(s) of the work to be used:_________(e.g. article title; vol.; etc.)

This material will be used for (description of intended use e.g. in the following course) in compliance with copyright law. The above mentioned material will be made available only to students enrolled in the class for instructional purposes on a nonprofit basis. The copyright notice will appear on all distributed material.

I would appreciate your consent. Please indicate your approval by signing where indicated below and return this letter in the enclosed envelope at your earliest convenience. If there is any other person whose consent might be required, please indicate so at the end of this letter.
______________________________________________________________

If you are the holder of copyright:
_____I (type name of addressee) give my permission.
_____I (type name of addressee) give my permission subject to the conditions stated below.
_____I (type name of addressee) do not give my permission.

Please indicate conditions, if any, that you require.
_______________________________________________________________
_______________________________________________________________.

Thank you.

Sincerely,

(Your name and signature)

Please initial any statement that applies:
_____I hereby represent that I have the authority to grant the permission requested herin.
_____I am the sole owner/author of the work.

_________________________________________
Authorized Signature
_________________________________________
Print name
_________________________________________
Title
_________________________________________
Company
_________________________________________
Address
_________________________________________
Date

Other persons to contact for consent:
Name(s):_____________________________________________
Address(es):_________________________________________
Phone:_______________________________________________

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